| | CHRONIC DIARRHEA
Doorway information about patient
The patient is a 34-year-old man who comes to the clinic due to 4 weeks of diarrhea.
Vital signs
. Temperature: 36.7’C (98.1F)
. Blood pressure : 118/78 mmHg
. Pulse: 86/min
. Respirations: 14/min
Approach to the patient
Acute diarrhea is usually a self-limited illness . Unless bloody stools , systemic symptoms (eg , fever), or signs of dehydration are present, most cases are manages conservatively and do not need an extensive investigation.
However , patient with chronic(> 4 weeks) diarrhea are less likely to have spontaneous resolution and warrant additional workup . Patient with usually soft but otherwise normal stools may use the term ”diarrhea” so the interview should begin by clarifying the frequency , volume , and consistency of stools.
Different diagnosis
Most patients who comes for evaluation of chronic diarrhea have one of the following:
. Functional diarrhea: loose stools without additional symptoms
. Irritable bowel syndrome: loose stools , altered bowel habits , sensation of incomplete
. Inflammatory bowel disease:
1, Crohn disease : watery diarrhea , fever m weight loss , abdominal pain
2, Ulcerative colitis : cramps , tenesmus (sensation of needing to strain to pass stool), visible blood
. Malabsorption : Increased stool volume , weight loss, steatorrhea , flatulence , possible association with foods(dairy products , gluten)
. Paradoxic diarrhea: impacted stool with diarrhea due to passage of watery stool around the impaction(especially in frail or elderly patient)
Patient with chronic diarrhea should be queried for foreign travel and risk factors for -HIV-, which would broaden the differential diagnosis significantly . Waterlyt diarrhea following exposure to rural or wildness water resource suggests -giardiasis- ; parasitic causes of chronic diarrhea are otherwise uncommon in the United States.
HISTORY AND PHYSICAL EXAMINATION
The following section include the most common items that should be included in the evaluation of a patient with diarrhea . In patients with chronic diarrhea , the history is usually more helpful than the physical examination.
History
History of [resent illness
. Please explain what you mean by “ diarrhea”
. When did the diarrhea start?
. How many times a day are you going?
. Do you have large or small volume?
. What is the pattern ? Are symptoms continuous m or do you have normal bowel movements in between?
. Do you see blood or pus?
. Do you pass mucus in the stool?
. Is the diarrhea greasy or oily?
. Do you have abdominal pain or cramps?
. Have you had fever , chills or weight loss?
. Is the diarrhea associated with any particular foods?
. Have you started any new medications, include over-the-counter medications?
. Are you taking weight loss pills (eg, orlistat) or artificial sweeteners(eg sorbitol)?
. Have you been traveling or camping recently?
. Dose anyone around you have similar symptoms?
Past medical history
. Have you had abdominal surgeries?
Social history
. Are you sexually attire ? Have you been active with men , women , or both?
. Do you use illicit drugs?
Physical examination
General
. Assess fluid & nutritional status (eg, tachycardia, orthostatic hypotension, decreased subcutaneous fat)
HEENT/Neck
. Examine oropharynx for ulcers , thrush.
. Inspect eyes for conjunctivitis, episcleritis.
. Palpate neck ofr enlarged lymph nodes , thyromegaly.
Abdomen
. Inspect for scars & distension.
. Auscultate for bowel sounds
. Percuss for bowel gas pattern.
. Palpate for tenderness , especially along the course of colon.
Closing the encounter
The closing conversation should review the most likely diagnosis and any clinical features that suggest serious illness . Discuss whether an aggressive evaluation is warranted or whether you should order tests in a stepwise fashion, If endoscopy is considered , provide basic education about the procedure and obtain the patient’s consent before proceeding.
Diagnostic studies
Virtually all patients with diarrhea should have a rectal examination ; this is not allowed in the USMLE Step 2 CS exam but should be listed in the Diagnostic studies section. Also , most patients warrant basic laboratory studies (eg, electrolytes , urea nitrogen, creatinine , blood counts , fecal occult blood) to assess serious and identify dehydration or other potential complications of the diarrhea.
Patient with bloody diarrhea or fever need an expedited evaluation with early colonoscopy . in contrast , patient with non bloody diarrhea and no systemic symptoms may warrant only a few basic laboratory tests and a trial of dietary modification before invasive studies.
Diagnostic tests to consider in chronic diarrhea include:
. Total protein , albumin(possible malabsorption)
. TSH
. Inflammatory markers (eg, erythrocytes , sedimentation rate, C-reactive protein)
. Quantitative stool fat
. Stool Guardia antigen
. Anti-tissue transglutaminase antibody assay(suspicion for celiac disease , comorbid type 1 diabetes)
. HIV serology
. Colonoscopy
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2018/06/05 10:46pm 
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